Co-Occurring Social Anxiety Disorder in Adults with Autism Spectrum Disorder

Background: Social Anxiety Disorder (SAD) tends to present in adolescence and persist into adulthood (Alfano et al., 2006), and symptoms of social anxiety are fairly common among people with ASD (e.g., Chang et al., 2012). Few studies have examined the presence of SAD in adults with ASD, but recent estimates in the range of 30% suggest that SAD is also common in this population, when intellectual disability is not present (Kreiser & White, 2013). A better understanding of co-occurring social anxiety, including its prevalence and how to accurately assess it, is critical for adults with ASD.   

Objectives: The primary objective was to examine the prevalence and manifestation of SAD in a non-treatment seeking sample of adults with ASD. Most research on social anxiety in individuals with ASD has focused on the physiological symptoms and behavioral avoidance, largely ignoring the influence of socially anxious cognitions. The current study aimed to collectively assess all three dimensions (i.e., physical, behavioral, and cognitive) of social anxiety, in order to fully explore the experience of social anxiety phenomenologically in ASD.  

Methods: The sample currently consists of 25 individuals with ASD (16-45 years old; 14 males) who participated in a one-session eye-tracking study. The target sample size of 30 participants is expected by December 2013. All participants have a confirmed ASD diagnosis, based on the ADOS, Second Edition (ADOS-2; Lord et al., 2012) and clinical interview. They also completed a brief cognitive assessment and the social anxiety module of the Anxiety Disorders Interview Schedule (ADIS; Brown et al., 1994). The ADIS was conducted by clinicians trained to reliability and knowledgeable about the distinctions between ASD characteristics and SAD symptoms.  

Results: Of the 25 participants, 12 (48%) met diagnostic criteria for SAD on the ADIS. Their qualitative descriptions highlight the bi-directional relationship between social anxiety and the social deficits associated with ASD. For example, one participant explained: “I don’t know what to do at a party. I have no idea how to keep a conversation going. I might ramble, and then people will judge me and think I’m odd or stupid.” Several participants also emphasized the role of past peer victimization in the development of their social anxiety symptoms, and the contribtion of social anxiety to isolation and loneliness. Of the 13 participants without SAD, many expressed a dislike of or disinterest in social situations, but they exhibited no explicit fear of negative evaluation from others.   

Conclusions: These findings demonstrate that many adults with ASD are acutely aware of their social difficulties and experience impairing social anxiety as they face increasing social complexities during adulthood. The accurate assessment and differential or dual diagnoses of ASD and SAD are challenging, and more research in this area is greatly needed, particularly with adults. Examining the presence or absence of the cognitive symptoms of SAD (e.g., concerns related to self-embarrassment and negative evaluation by others) may be useful for phenotyping and treatment planning with individuals with ASD. These cognitions may be related to social insight and social motivation.